When looking at this standard it is important to note
that
Paragraphs II & III A and B which come before
paragraph C state:
A "Site selection criteria should be
established in organizational policies and procedures and practice
guidelines."
B "Site selection should be determined per
manufacturer's labeled uses(s) and directions for device
insertions."
To me, as a clinician, I am covered under paragraphs A
& B if placing in the upper arm using ultrasound
imaging.
Currently there is very little scientific evidence
based practice published on the topic of comparing antecubital and upper
placement of PICCs. Most manuscripts, address increase in successful PICC
line placement rates in the upper arm using micro-introducer and ultrasound
imaging technology. Only antedotally is it mentioned that there is a
decrease in mechanical phlebitis and an increase in patient and nursing
satisfaction not having the PICC placed in the region around the antecubital
fossa.
The use of micro-introducers and ultrasound imaging
with nursing is still only a small percent of the total number of PICCs placed
by nursing. There are many facilities and agencies that place PICCs using
the traditional approach of sight and feel and place in the antecubital fossa
regional and report that they have good outcomes. Nurses are good at
what they do.
Antedotal evidence is OK
and is considered but it is not considered rigorous scientific study.
Outcome data analysis carries a little more weight and should be published
more than it is in this area. However, like everybody else in our field,
our time is so involved in patient care and management that publishing is low on
our priority list. Best would be research in this area involving a more
rigorous scientific study comparing both areas of placement (antecubital fossa
vs upper arm). Again our time is limited at work and the time involved in
getting an approved study through the IRB at the facilities we work at and the
time necessary to carry out the study is very involved and time consuming.
Nursing Research is not a high priority for many
institutions.
We all need to be tracking our data on PICCs and
complications and have the data published.
Bottom line here - "The Infusion
Nursing Standards of Practice", revised 2006 edition, cannot put a standard
in that is not backed up by rigorous scientific study even though
antedotally we see better outcomes. It has been published over and over
again that nurses can place PICC lines safely in the antecubital fossa
region.
Timothy Royer, BSN, CRNI
Nurse Manager / Vascular Access / Diagnostic
Service
VA Puget Sound Health Care System
Seattle / Tacoma, WA
Disclaimer - This are my personal beliefs and do not
represent the institution I work at.
From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf Of CAROLYN
Sent: Sunday, January 29, 2006 7:40 AM
To: [EMAIL PROTECTED]
Subject: INS standard # 37
# 37 Site Selection - Practice
Criteria: II Peripheral-Midline and III PICC it states:
Site selection should be routinely initiated
in the region of the antecubital fossa; veins that should be considered for
cannulation are the basilic, median cubital, cephalic, and the
brachial.
When we use ultrasound we are hardly ever
placed in the antecubital fossa because of the larger catheters being required,
increase in antecubital complications because of movement and of course patient
comfort.
What are the legal implications of this in
court by not using the antecubital for
placement? Thanks
